Examining Adult Mental Health in the United States

Supplement / Vol. 60 September 2, 2011

U.S. Department of Health and Human ServicesCenters for Disease Control and Prevention

Morbidity and Mortality Weekly Report

Mental Illness Surveillance Among Adults in the United States

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60(Suppl):[inclusive page numbers].

Centers for Disease Control and PreventionThomas R. Frieden, MD, MPH, Director

Harold W. Jaffe, MD, MA, Associate Director for ScienceJames W. Stephens, PhD, Director, Office of Science Quality

Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory ServicesStephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office

MMWR Editorial and Production StaffRonald L. Moolenaar, MD, MPH, Editor, MMWR SeriesChristine G. Casey, MD, Deputy Editor, MMWR Series

Frederic E. Shaw, MD, JD, Guest Editor Teresa F. Rutledge, Managing Editor, MMWR Series

David C. Johnson, Lead Technical Writer-EditorCatherine B. Lansdowne, MS, Project Editor

Martha F. Boyd, Lead Visual Information SpecialistJulia C. Martinroe, Stephen R. Spriggs, Terraye M. Starr

Visual Information SpecialistsQuang M. Doan, MBA, Phyllis H. King

Information Technology Specialists

MMWR Editorial BoardWilliam L. Roper, MD, MPH, Chapel Hill, NC, Chairman

Virginia A. Caine, MD, Indianapolis, INJonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA

David W. Fleming, MD, Seattle, WAWilliam E. Halperin, MD, DrPH, MPH, Newark, NJ

King K. Holmes, MD, PhD, Seattle, WADeborah Holtzman, PhD, Atlanta, GA

John K. Iglehart, Bethesda, MDDennis G. Maki, MD, Madison, WI

Patricia Quinlisk, MD, MPH, Des Moines, IAPatrick L. Remington, MD, MPH, Madison, WI

Barbara K. Rimer, DrPH, Chapel Hill, NCJohn V. Rullan, MD, MPH, San Juan, PR

William Schaffner, MD, Nashville, TNAnne Schuchat, MD, Atlanta, GA

Dixie E. Snider, MD, MPH, Atlanta, GAJohn W. Ward, MD, Atlanta, GA

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CONTENTSIntroduction ............................................................................................................2

Background .............................................................................................................2

Role of Surveillance in Reducing Morbidity and Mortality Associated with Mental Illness ...................................................................2

Diagnostic Classification of Mental Illness ................................................2

Methods for Measuring Prevalence and Public Health Impact of Mental Illness ...................................................................................................3

CDC Surveillance Systems and Surveys that Measure Prevalence and Impact of Mental Illness ...................................................................................4

Population Surveys ...........................................................................................5

National Health-Care Surveys .......................................................................7

Findings from CDC Surveillance Systems and Surveys ............................8

Population Surveys ...........................................................................................8

National Health-Care Surveys .......................................................................9

Discussion ............................................................................................................ 10

Acknowledgments ............................................................................................. 11

References ............................................................................................................ 11

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MMWR / September 2, 2011 / Vol. 60 1

Mental Illness Surveillance Among Adults in the United StatesWilliam C. Reeves, MD1

Tara W. Strine, PhD1

Laura A. Pratt, PhD2

William Thompson, PhD3

Indu Ahluwalia, PhD3

Satvinder S. Dhingra, MPH4

Lela R. McKnight-Eily, PhD3

Leslie Harrison, MPH 3

Denise V. D’Angelo, MPH3

Letitia Williams, MPH3

Brian Morrow, MA3

Deborah Gould, PhD1

Marc A. Safran, MD51Public Health Surveillance Program Office

2National Center for Health Statistics3National Center for Chronic Disease Prevention and Health Promotion

4Northrop Grumman 5 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Summary

Mental illnesses account for a larger proportion of disability in developed countries than any other group of illnesses, including cancer and heart disease. In 2004, an estimated 25% of adults in the United States reported having a mental illness in the previ-ous year. The economic cost of mental illness in the United States is substantial, approximately $300 billion in 2002. Population surveys and surveys of health-care use measure the occurrence of mental illness, associated risk behaviors (e.g., alcohol and drug abuse) and chronic conditions, and use of mental health–related care and clinical services. Population-based surveys and surveil-lance systems provide much of the evidence needed to guide effective mental health promotion, mental illness prevention, and treatment programs.

This report summarizes data from selected CDC surveillance systems that measure the prevalence and impact of mental ill-ness in the U.S. adult population. CDC surveillance systems provide several types of mental health information: estimates of the prevalence of diagnosed mental illness from self-report or recorded diagnosis, estimates of the prevalence of symptoms associated with mental illness, and estimates of the impact of mental illness on health and well-being. Data from the CDC 2005–2008 National Health and Nutrition Examination Survey indicate that 6.8% of adults had moderate to severe depression in the 2 weeks before completing the survey. State-specific data from the CDC 2006 Behavioral Risk Factor Surveillance System (BRFSS), the most recent BRFSS data available, indicate that the prevalence of moderate to severe depression was generally higher in southeastern states compared with other states. Two other CDC surveys on ambulatory care services, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, indicate that during 2007–2008, approximately 5% of ambulatory care visits involved patients with a diagnosis of a mental health disorder, and most of these were classified as depres-sion, psychoses, or anxiety disorders.

Future surveillance should pay particular attention to changes in the prevalence of depression both nationwide and at the state and county levels. In addition, national and state-level mental illness surveillance should measure a wider range of psychiatric conditions and should include anxiety disorders. Many mental illnesses can be managed successfully, and increasing access to and use of mental health treatment services could substantially reduce the associated morbidity.

Corresponding author: William C. Reeves, MD, Public Health Surveillance Program Office, CDC, 1600 Clifton Rd., N.E., MS E-97, Atlanta, GA 30333. Telephone: 404-498-6521; Fax: 404-498-1177; E-mail: [email protected].

mailto:[email protected]

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2 MMWR / September 2, 2011 / Vol. 60

IntroductionMental illness refers collectively to all diagnosable mental

disorders and is characterized by sustained, abnormal altera-tions in thinking, mood, or behavior associated with distress and impaired functioning (1). Mental illness is an important public health problem, both in its own right and because the condition is associated with other chronic diseases and their resulting morbidity and mortality. According to the World Health Organization (WHO), mental illnesses account for more disability in developed countries than any other group of illnesses, including cancer and heart disease (2). Approximately one fourth of adults in the United States have a mental illness, and nearly half will develop at least one mental illness during their lifetime (3–5). The most common mental illnesses in adults are anxiety and mood disorders (4). The effects of mental illness range from minor disruptions in daily functioning to incapacitating personal, social, and occupational impairments and premature death (6–9). In 2002 and 2003, mental illness cost the United States an estimated $300 billion annually, which included approximately $193 billion from lost earnings and wages and $24 billion in disability benefits in 2002 (10) and $100 billion in health-care expenditures in 2003 (11).

Mental illness exacerbates morbidity from the multiple chronic diseases with which it is associated, including car-diovascular disease, diabetes, obesity, asthma, epilepsy, and cancer (12–16). This increased morbidity is a result of lower use of medical care and treatment adherence for concurrent chronic diseases and higher risk for adverse health outcomes (17–20). Rates for injuries, both intentional (e.g., homicide and suicide) and unintentional (e.g., motor vehicle), are 2–6 times higher among persons with a mental illness than in the overall population (21,22). Mental illness also is associated with use of tobacco products and alcohol abuse (23).

This report summarizes data from selected CDC surveil-lance and information systems that measure mental illness and the associated effects in the U.S. adult population. The data presented include 1) the occurrence and associated effects of mental illness among adults in the United States as measured through selected CDC surveillance and information systems, 2) the CDC systems involved in the collection of mental ill-ness data for adults and the associated public access databases, and 3) estimates from other studies and surveys, particularly those conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), compared with CDC system estimates.

BackgroundRole of Surveillance in Reducing

Morbidity and Mortality Associated with Mental Illness

Public health surveillance is the ongoing and systematic col-lection, analysis, interpretation, and dissemination of data used to develop public health interventions that reduce morbidity and mortality and improve health (24). Surveillance for a particular condition might depend either on collection of new data or use of data obtained from existing health information systems (e.g., from vital statistics or public health surveys). Surveillance data have numerous uses in public health: 1) determination of the distribution and spread of disease, 2) estimation of the impact of a disease or injury, 3) generation of hypotheses and stimulation of research, 4) development of public health interventions, 5) description of the history of a health condition and the impact of treatments on outcomes, 6) evaluation of prevention and control measures, and 7) facilita-tion of program planning (25). Because a single surveillance system typically cannot accomplish all of these tasks, use of multiple surveillance systems often provides a more complete assessment of a particular disease or condition.

Surveillance data are essential to the public health goals of reducing the incidence, prevalence, severity, and economic impact of mental illnesses. Public health officials, academi-cians, health-care providers, and advocacy groups need accu-rate and timely information on the prevalence and effects of mental illness to detect and characterize trends in mental illness prevalence and severity (26); assess associations between mental illness and other chronic medical conditions (e.g., obe-sity, diabetes, heart disease, and alcohol and substance abuse); identify populations at high risk for mental illness and target interventions, treatment, and prevention measures; and provide outcome measures for evaluating mental illness interventions. For example, officials have used metal illness surveillance data to track trends in mental illness and psychological distress associated with exposure to military combat or large-scale disasters (27).

Diagnostic Classification of Mental IllnessPopulation surveys can be used to estimate accurately the

prevalence of certain mental illness symptoms across popula-tions, and by repeating surveys over time, they can be used to detect and characterize trends. Surveys generally cannot be used to diagnose mental disorders with the same level of specificity as an individual clinical examination conducted by an experienced psychiatrist or other mental health professional. Instead, they

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collect information on a range of subjective manifestations of alterations in thinking, mood, behavior, and associated distress that correspond with clinical disorders. Surveys collect this information using participant questionnaires that have been validated empirically to distinguish between persons with and without specific mental illnesses or general psychological distress. Estimates from these surveys vary according to the symptoms being collected and the way they correspond with various defined mental illnesses. Survey estimates usually are based on carefully defined patterns of symptoms. The most commonly used patterns correspond with diagnostic criteria agreed on by mental health professionals.

The symptom patterns used for surveys vary according to the classification of mental illness under study; changes in these classifications over time have increased the complexity of matching symptom patterns to specific illnesses. New clas-sifications have been identified, and certain classifications have been removed. Even for relatively stable diagnostic categories (e.g., depression), subcategories and terminology have varied over time. For example, terms used to describe depression have included major and minor depression, psychotic depression, depression not otherwise specified, bipolar disorder, dysthy-mia, moderate to severe depression, and mild depression. However, the relationship among the disorders described by these different terms often is unclear. The American Psychiatric Association (APA) developed mental illness diagnostic catego-ries based on symptoms observed by a health professional or reported by the patient; the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) is the current version of this system (28). Another system, the WHO International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), defines mental illness categories that are similar but not identical to those in the DSM-IV-TR (29). Previous DSM and ICD versions have not been completely congruent, and APA is developing a fifth edition of the DSM (DSM-V) that will coordinate better with future editions of ICD (30).

Methods for Measuring Prevalence and Public Health Impact of Mental Illness

Research Instruments The Structured Clinical Interview for DSM Disorders

(SCID) Research Version (31) is considered to be the standard among psychiatric research instruments based on DSM-IV-TR criteria; however, SCID takes 30–60 minutes and must be conducted by a trained mental health professional. Another instrument, the Composite International Diagnostic Interview (CIDI), was developed by WHO and is based on ICD-10

mental illness criteria. CIDI also is intended for use in epide-miological, clinical, and research studies. CIDI is lengthy, like SCID, but may be administered by trained lay interviewers (32). SCID and CIDI identify overlapping but not necessar-ily identical populations because they are based on different classification systems.

Screening InstrumentsLarge surveys that focus on a wide range of health topics

typically can include only a limited number of mental health questions and often rely on SCID- or CIDI-validated screen-ing instruments to provide indicators of psychiatric-related symptoms; in some cases, statistical models are used to predict the likelihood of specific mental illness in the respondent based on rating scales. Several standardized and validated screening instruments can be used to identify persons with mental illnesses such as depression and psychological distress, with varying degrees of diagnostic sensitivity and specificity (33–35). CDC surveys use these screening instruments, as well as other standardized questions, to assess mental illness and other measures, such as impaired quality of life (e.g., mentally unhealthy days) and health-related disability associated with mental illness.

Depression (Patient Health Questionnaire-8 and Patient Health Questionnaire-9)

Depression is a major focus of population surveys of mental illness. To meet the DSM-IV-TR definition of major depressive disorder, a person must have either a depressed mood or a loss of interest or pleasure in daily activities consistently for at least 2 weeks. This mood must represent a change from the person’s normal mood; social, occupational, educational, or other important functioning also must be impaired by the change in mood. Under the DSM-IV-TR, a depressed mood that is caused by substances (e.g., drugs, alcohol, or medications) or that is part of a general medical condition is not considered to be major depressive disorder (28).

One of the most widely used and validated instruments for measuring depression in population surveys is the nine-item Patient Health Questionnaire (PHQ-9). The PHQ-9 screens for the presence of the nine DSM-IV-TR criteria for acute and clinically significant depressive disorders (36). A PHQ-9 score of ≥10 has high sensitivity (88%) and specificity (88%) when validated against SCID (37) and effectively detects depressive symptoms among persons of various races and ethnicities (38,39). The PHQ-9 has been used as a self-administered module in many clinical studies and telephone-administered surveys (38,40–43).

Other telephone surveys have used a slightly shorter instru-ment, the eight-item Patient Health Questionnaire (PHQ-8),

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which omits the PHQ-9 question concerning suicidal or self-injurious ideation because survey administrators might not be able to offer appropriate follow-up interventions. Omitting this question in population-based surveys has only a minor effect on the usefulness of PHQ as a screen for depression (36).

The standard PHQ-8 and PHQ-9 have the following pri-mary question: “Over the last 2 weeks, how often have you been bothered by any of the following problems?” The follow-ing problems are listed: 1) little interest or pleasure in doing things; 2) feeling down, depressed, or hopeless; 3) trouble falling/staying asleep, sleeping too much; 4) feeling tired or having little energy; 5) poor appetite or overeating; 6) feeling bad about yourself or that you are a failure or have let yourself or your family down; 7) trouble concentrating on things, such as reading the newspaper or watching television; 8) moving or speaking so slowly that other people could have noticed, or the opposite — being so fidgety or restless that you have been moving around a lot more than usual; and 9) (PHQ-9 only) thoughts that you would be better off dead or of hurt-ing yourself in some way. Response categories are “not at all,” “several days,” “more than half the days,” and “nearly every day.”

PHQ-8 and PHQ-9 answers are scored using one of two algorithms, and the scores are used to assign depression catego-ries. One algorithm is based on the DSM-IV and categorizes depressed respondents as having a major depressive disorder or other depression. The other algorithm categorizes respondents according to the severity of depressive symptoms (i.e., no sig-nificant depressive symptoms or mild, moderate, moderately severe, or severe depressive symptoms) (36,37).

Psychological Distress (Kessler-6 Psychological Distress Scale)

Surveys use the Kessler-6 psychological distress scale to screen for psychological distress experienced by persons with anxiety and mood disorders (44). The Kessler-6 scale asks respondents about the frequency with which they have experienced six manifestations of psychological distress, which include feel-ing 1) nervous, 2) hopeless, 3) restless or fidgety, 4) so sad or depressed that nothing could cheer the respondent up, 5) that everything is an effort, and 6) worthless. Responses are “all of the time,” “most of the time,” “some of the time,” “a little of the time,” and “none of the time.” Scoring of individual items is based on a 4-point scale according to increased frequency of the problem, yielding a total six-item score ranging from 0–24. A score of ≥13 indicates serious psychological distress (45). Serious psychological distress as defined by the Kessler-6 score is highly associated with anxiety disorders and depression but does not identify a specific mental illness (44).

Mentally Unhealthy DaysHealth-related quality of life (HRQOL) is a multidimen-

sional concept that includes physical, mental, emotional, and social domains and reflects perceived physical and mental health (46,47). HRQOL often is used to characterize certain aspects of disease impact, disability, and injury and to identify unmet health needs and disparities among various sociodemo-graphic populations (48). A core set of four questions (i.e., the Healthy Days Core Module, or HRQOL-4) has been standardized and validated for public health survey purposes. HRQOL-4 asks respondents about self-rated general health, physical health, mental health, and activity limitations result-ing from poor physical or mental health during the previous 30 days (48). One indicator often used to measure HRQOL is the number of mentally unhealthy days experienced by a person. Typically, the question asks: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Respondents who report ≥14 mentally unhealthy days over the past month are defined as having frequent mental distress. The mentally unhealthy days question has acceptable criterion validity and test-retest reliability (48–50). In a large prospective study, this question predicted 1-month and 12-month physician visits, hospitaliza-tions, and mortality outcomes (51).

Health-Care SurveysData from health-care providers and insurers provide an

additional important source of information on the prevalence of mental illness in the United States. Coding systems used by hospitals and medical providers for billing purposes typically use the ICD-9 coding system, which, as mentioned previously, is not completely congruent with the DSM-IV-TR. In addition, men-tal health professionals generally use the DSM-IV-TR nomen-clature, whereas primary care providers use other terminology. In practice, regardless of the diagnostic system used, diagnoses vary according to the training of the coder, local practice, availability of treatment resources, and reimbursement codes.

CDC Surveillance Systems and Surveys that Measure Prevalence and

Impact of Mental IllnessCDC systems for measuring the prevalence and impact

of mental illness in the U.S. adult population fall into two categories: 1) population surveys, which are used to estimate mental illness prevalence, and 2) national health-care surveys that include a diagnosed psychiatric condition based on ICD-9

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codes, which are used to estimate outpatient visits and hospital-izations and reflect access to and use of health care by persons with mental illness (Table 1). Both of these systems provide public access data sets that allow researchers to address specific queries or conduct specific analyses. In combination with information from other studies and surveys, notably surveys conducted by SAMHSA, data from these CDC systems can be used to plan, implement, and evaluate mental illness pre-vention strategies and to explore ways to protect and promote mental health. Proper interpretation of mental health surveil-lance statistics requires an understanding of 1) the reason the data were collected (e.g., to identify prevalence or for program planning); 2) the survey population (e.g., representative of state or national population, sample frame, and time conducted); 3) survey methods (e.g., telephone vs. in-person interviews, record reviews or abstracts, and vital statistics); 4) question-naires and questions used (e.g., standardization, validity, and reliability); 5) parameters measured (population prevalence and effects of the illness); and 6) appropriate analyses (adjustment and weighting for survey designs and response rates, rates, proportions, and continuous measures).

Population SurveysBRFSS

BRFSS is a state-based telephone survey that was established in 1984.* BRFSS is the largest ongoing telephone health survey in the world, with approximately 450,000 adult interviews completed each year. BRFSS collects standardized, state-specific data concerning preventive health practices and risk behaviors associated with infectious diseases, chronic diseases, and injuries in the adult population. Data are collected in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. The large size of the survey permits calcu-lation of state-specific estimates (and in some cases, substate estimates) and aggregated nationwide estimates. States use BRFSS data to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs. For many states, BRFSS is the only source of timely, accurate, state-based data on health-related behaviors.

BRFSS interviews consist of three parts: 1) core questions asked in all states and territories (e.g., demographics, HRQOL, access to health care, disability, chronic conditions, and risk behaviors); 2) optional modules with questions on specific topics (for mental illness: the anxiety and depression module and the mental illness and stigma module); and 3) questions added by individual states. BRFSS data are directly weighted

for the probability of selection of a telephone number, the number of adults in a household, and the number of landline telephone numbers that reach a household. Data are then stratified to adjust for nonresponse, to adjust for noncover-age of households without telephones, and to force the sum of the weighted frequencies to equal the adult population in each state.

Every year, the core BRFSS includes a question on number of mentally unhealthy days as a measure of HRQOL. States also may administer BRFSS optional modules (conducted through a collaboration between CDC and SAMHSA) that address other mental health topics in depth. In 2006, 2008, and 2010, an optional BRFSS module on anxiety and depression contained the PHQ-8, one question on lifetime diagnosis of anxiety, and one question on lifetime diagnosis of depression. In 2007 and 2009, an optional BRFSS module on mental illness and stigma included the Kessler-6 scale (past 30 days), one question on activity limitations associated with a mental health condition or emotional problem, one question on treat-ment, and two questions on attitudes toward mental illness that might underlie stigma. Because certain individual states do not use these optional modules, BRFSS cannot provide national estimates of depression or psychological distress.

CDC provides public online access to the following summary statistics from various BRFSS modules:

• Prevalence and trends data: prevalence estimates for core variables by year and by state from 1995 to the present†

• Selected metropolitan/micropolitan area risk trends (SMART) city and county data: CDC information on all health risk data for metropolitan and micropolitan statisti-cal areas (MMSAs) by year and category, with users able to generate reports that compare statistics by MMSA and to use SMART to produce charts that show state, MMSA, and county data for a limited set of health risk factors (2002–2008)§,¶

• BRFSS maps: MMSA maps for many core variables (2002–present)** and annual BRFSS survey data and technical documentation so that researchers can conduct their own analyses

• Yearly state-based survey data sets and technical documen-tation (1984–present)††

* Additional information available at http://www.cdc.gov/brfss/index.htm.

† Additional information available at http://apps.nccd.cdc.gov/brfss. § Additional information available at http://apps.nccd.cdc.gov/brfss-smart/

index.asp. ¶ Additional information available at http://apps.nccd.cdc.gov/brfss-smart/

selquickviewchart.asp. ** Additional information available at http://apps.nccd.cdc.gov/gisbrfss/default.aspx. †† Additional information available at http://www.cdc.gov/brfss/technical_

infodata/surveydata.htm.

http://www.cdc.gov/brfss/index.htm

http://apps.nccd.cdc.gov/brfss

http://apps.nccd.cdc.gov/brfss-smart/index.asp

http://apps.nccd.cdc.gov/brfss-smart/index.asp

http://apps.nccd.cdc.gov/brfss-smart/selquickviewchart.asp

http://apps.nccd.cdc.gov/brfss-smart/selquickviewchart.asp

http://apps.nccd.cdc.gov/gisbrfss/default.aspx

http://www.cdc.gov/brfss/technical_infodata/surveydata.htm

http://www.cdc.gov/brfss/technical_infodata/surveydata.htm

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• Yearly data sets and technical documentation for counties and MMSAs with ≥500 respondents (2002–present)§§

• Yearly data and technical documentation for state and MMSA geographic information system data files (2002–present)¶¶

National Health Interview SurveyThe National Health Interview Survey (NHIS) is a con-

tinuous cross-sectional survey of the civilian U.S. household population. NHIS monitors the health of the U.S. population through the collection and analysis of data on a broad range of health topics.*** Data are collected through an in-person household interview. The basic module, which remains largely unchanged from year to year, includes three components: a family core questionnaire, a sample adult core questionnaire, and a sample child core questionnaire. The family core col-lects information on everyone in the family and serves as the sampling frame for additional integrated surveys. This core includes information concerning household composition and sociodemographic characteristics, tracking information, information for linkage to administrative databases, indicators of health status, activity limitations, injuries, health insurance coverage, and access to and use of health-care services. One adult and one child (if any children aged <18 years are present) are selected randomly from each family, and information on each is collected with the sample adult core and sample child core questionnaires. Because certain health issues are different for adults and children, certain items on these two question-naires differ; however, both collect basic data on health status, health-care services, and behavior. These sections of the survey yield the sample adult and the sample child data files.

NHIS uses a multistage area probability design to identify representative U.S. households. The sample is redesigned and redrawn approximately every 10 years to more accurately measure the changing population and to meet new survey objectives. NHIS oversamples blacks, Hispanics, and Asians (especially those aged ≥65 years) to allow for more precise estimation of health characteristics in these growing minority populations. The NHIS sample size (approximately 10,000) is not sufficient to provide reliable state-level estimates for most states. Although the database does not identify respondents’ state of residence, state-level estimates can be produced for more populous states by requesting state identifiers through the CDC National Center for Health Statistics (NCHS) Research Data Centers.†††

NHIS sample weights, which account for the differential probabilities of selection, nonresponse, and noncoverage, must be used for all analyses. Methods that incorporate the complex sample design and weights (e.g., Taylor series linearization) must be used to calculate appropriate standard errors.

Since 1997, NHIS has used the Kessler-6 scale (past 30 days) to identify serious psychological distress among adults. National rates for psychological distress by age, sex, and race are produced quarterly through the NHIS Early Release Program and are available online. In 2007, the NHIS included three questions on lifetime diagnoses: “Have you EVER been told by a doctor or other health professional that you had bipolar disorder? Schizophrenia? Mania or psychoses?”

National Health and Nutrition Examination Survey

The National Health and Nutrition Examination Survey (NHANES) is a continuous survey of the health and nutritional status of the U.S. civilian noninstitutionalized population.§§§ Although NHANES uses a multistage probability household sampling design to obtain a nationally representative sample, the sample is not sufficient for state- or local-level analyses. NHANES sample weights, which account for the differential probabilities of selection, nonresponse, and noncoverage, must be used for all analyses. Survey participants complete an interview administered in their home and then are invited to participate in an examination conducted in a mobile examina-tion center. This includes a private interview, a standardized physical examination, and collection of biological specimens for laboratory testing. NHANES collects data on the prevalence of 1) chronic diseases and conditions (including undiagnosed conditions detected through the examination or laboratory testing) and risk factors (e.g., obesity, smoking, serum choles-terol levels, hypertension, and diet and nutritional status), 2) vaccination status, 3) infectious disease prevalence, 4) health insurance, and 5) measures of environmental exposures. Other topics include hearing, vision, anemia, diabetes, cardiovascular disease, osteoporosis, oral health, pharmaceuticals and dietary supplements, physical fitness, HRQOL, and health-care use. In the private mobile examination center interview, NHANES uses the PHQ-9 to measure depression, and since 2000, this NHANES interview also has included the question on number of mentally unhealthy days. The examination and laboratory data collected allow researchers to examine the relationships between depression and health variables not available on other national surveys. §§ Additional information available at http://www.cdc.gov/brfss/smart/

technical_infodata.htm. ¶¶ Additional information available at http://www.cdc.gov/brfss/maps/gis_data.htm. *** Additional information available at http://www.cdc.gov/nchs/nhis.htm. ††† Additional information available at http://www.cdc.gov/rdc.

§§§ Demographic, questionnaire, examination, and laboratory data sets are available at http://www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm.

http://www.cdc.gov/brfss/smart/technical_infodata.htm

http://www.cdc.gov/brfss/smart/technical_infodata.htm

http://www.cdc.gov/brfss/maps/gis_data.htm

http://www.cdc.gov/nchs/nhis.htm

http://www.cdc.gov/rdc

http://www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm

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Pregnancy Risk Assessment Monitoring SystemThe Pregnancy Risk Assessment Monitoring System

(PRAMS) was established in 1987 and is a state-based, cross-sectional survey of women who have recently delivered a live-born infant. PRAMS provides population-based data that can be used to develop maternal and infant health programs and policies.¶¶¶ The survey uses a mixed-mode data collection method. Each month, randomly selected women who have delivered a live-born infant are requested to complete a mail questionnaire; follow-up with nonresponders occurs by phone. Data are collected in 37 states and New York City, representing approximately 75% of the births in the United States. Data are weighted to adjust for survey design, nonresponse, and noncoverage.

PRAMS collects information on maternal behaviors, atti-tudes, and experiences before, during, and after pregnancy. Survey responses are linked to birth certificate data. The questionnaire includes core questions asked of all participants in all states, optional standard questions pretested by CDC, and state-developed questions. PRAMS provides estimates of postpartum depression by using two questions similar to those included in the PHQ-8: 1) “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and 2) “Since your new baby was born, how often have you had little interest in doing things?” Possible responses are “never,” “rarely,” “sometimes,” “often,” and “always.” Women who answer “often” or “always” to either question or both questions are categorized as having postpartum depression.

CDC provides access to PRAMS data electronically through CPONDER (CDC’s PRAMS On-line Data for Epidemiologic Research).**** CPONDER provides access to prevalence estimates by state and by year (2000–2008). In addition, CPONDER indexes 54 variables by topic for selection as the outcome variable in cross-tabular analyses. Twelve control variables may be used to stratify these outcomes in an analysis. Analyses may include a single state and all available years or all available states and a single year.

National Health-Care SurveysCDC conducts surveys of health-care providers, and the data

from these surveys complement data from the population-based surveys to provide a more complete representation of the occurrence of mental illness in the United States. For the health-care surveys, CDC collects data from a sample of organizations that provide health care (e.g., nursing homes, inpatient hospitals, or physician offices). The data can be used

to examine factors that influence use of health-care resources, quality of health care, and disparities in health-care services in population subgroups. In addition, because the surveys col-lect core information from a sample of providers that remains relatively stable over time, trends in the types of care delivered in each setting can be monitored and examined in relation to the characteristics of providers, patients, and clinical manage-ment of patient care.

National Ambulatory Medical Care SurveyThe National Ambulatory Medical Care Survey

(NAMCS)†††† collects information on the use of ambulatory care services in the United States. NAMCS uses a multistage probability sample of visits to office-based physicians and health-care providers in community health centers and collects data on provider characteristics. Sample data are weighted to produce national estimates that describe the provision and use of ambulatory medical care services in the United States. Public use data files are released annually and include a visit statistical weight and (since 2005) a physician statistical weight. Information on mental health and mental illness available from NAMCS includes reasons for visit, physician diagnosis, medications, treatment, referrals, and one item on comorbid depression. Physician diagnoses are recorded as written by the physician (text or ICD-9 codes). Nosologists convert text to ICD-9 codes for the data files.

National Hospital Ambulatory Medical Care Survey

The National Hospital Ambulatory Medical Care Survey (NHAMCS)†††† collects data on the use of ambulatory care services in hospital emergency and outpatient departments. NHAMCS involves a multistage probability sample of visits to the emergency and outpatient departments of noninstitutional, general, and short-stay hospitals in the United States. Federal, military, and U.S. Department of Veterans Affairs hospitals are not included. Data collected from outpatient departments are similar to those collected by NAMCS. Data from emergency department visits are slightly different from the outpatient department data and include whether the patient was admitted to a mental health unit or transferred to a psychiatric hospi-tal. Sample data are weighted to produce national estimates. Public-use data files are released annually.

National Hospital Discharge SurveyThe National Hospital Discharge Survey (NHDS)§§§§

obtains national-level information on characteristics of

¶¶¶ Additional information available at http://www.cdc.gov/prams. **** Additional information available at http://www.cdc.gov/prams/

CPONDER.htm.

†††† Additional information available at http://www.cdc.gov/nchs/ahcd.htm. §§§§ Additional information available at http://www.cdc.gov/nchs/nhds.htm.

http://www.cdc.gov/prams

http://www.cdc.gov/prams/CPONDER.htm

http://www.cdc.gov/prams/CPONDER.htm

http://www.cdc.gov/nchs/ahcd.htm

http://www.cdc.gov/nchs/nhds.htm

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inpatients discharged from nonfederal, short-stay (<30 days) hospitals in the United States. Only hospitals with an average length of stay of <30 days, general hospitals, and children’s gen-eral hospitals are included in the survey. Psychiatric hospitals with an average length of stay of <30 days are eligible. NHDS does not include federal, military, U.S. Department of Veterans Affairs hospitals, prison hospitals, or hospitals with fewer than six beds. Hospitals are selected by using a three-stage stratified design. Patient information collected includes demographics, length of stay, diagnoses, and procedures. Hospital characteris-tics collected include region, ownership, and number of beds. NHDS sample statistical weights account for nonresponse and must be used for all analyses. Methods that incorporate the complex sample design and weights, such as Taylor series linear-ization, must be used to calculate appropriate standard errors.

National Nursing Home SurveyThe National Nursing Home Survey (NNHS)¶¶¶¶ is a con-

tinuous series of national sample surveys of nursing homes and their residents and staff members. NNHS provides information on nursing homes from the perspectives of the provider and recipient of services. Data on facilities include characteristics such as number of beds, ownership, affiliation, Medicare and Medicaid certification, specialty units, services offered, number and characteristics of staff, expenses, and charges. Data on current residents include demographic characteristics, health status, up to 16 current diagnoses, level of assistance needed with activities of daily living, vision and hearing impairment, continence, services received, and sources of payment. The survey uses a stratified two-stage probability design. The first stage is the selection of facilities, and the second stage is selec-tion of residents.

Findings from CDC Surveillance Systems and Surveys

Through the surveys and surveillance systems described in this report, CDC provides prevalence estimates on current depression, postpartum depression, psychological distress, number of mentally unhealthy days, and lifetime diagnosis of depression, anxiety, bipolar disorder, and schizophrenia in the U.S. adult population. CDC health-care surveys provide health services information about physician, hospital outpatient, and emergency department visits related to mental illness. All of these CDC systems can provide data for national-level (or nationwide) estimates by sex, age, race, and ethnicity. BRFSS and PRAMS data also can be used for state-level estimates.

Population SurveysCurrent Depression

Two CDC surveillance systems provide estimates for cur-rent depression: NHANES (national estimates) and BRFSS (state estimates). These systems use the PHQ-9 (NHANES) or PHQ-8 (BRFSS) to estimate the occurrence of depression in the last 2 weeks. For example, using continuously collected data from 2005–2008 (the most recent data available), results from NHANES indicate that 6.8% of U.S. adults had depres-sion (measured by the PHQ-9) during the 2 weeks before the survey (Table 2).

Results from BRFSS for current depression (measured by the PHQ-8) vary according to the year conducted because in differ-ent years, a varying number of states might have administered the optional modules containing the mental illness–related questions. Results from 2006 (in 38 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands) using the PHQ-8 indicate that approximately 8.7% of respondents had current depression. Results from 2008 in 16 states using the optional BRFSS anxiety and depression module indicate that 8.2% had current depression. Prevalence estimates were higher among women and non-Hispanic blacks compared with other groups (Table 3).

Using the PHQ-8 algorithm for major depressive disorder (36), the 2006 BRFSS prevalence estimate of major depression during the previous 2 weeks was 3.5% (95% confidence inter-val [CI]: 3.3–3.7) and in 2008 was 3.0% (95% CI: 2.8–3.3). BRFSS state-specific prevalence estimates for depression in 2006 and 2008 show marked variations from state to state, with prevalences ranging from 4.3% in North Dakota to 13.7% in Mississippi and West Virginia (Table 4). The prevalence of depression was generally highest in the southeastern states (Figure 1).

Postpartum DepressionDuring 2004–2008, a total of 14.5% of PRAMS respondents

reported symptoms of postpartum depression (i.e., answered “often” or “always” to either or both of the following questions): 1) “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and 2) “Since your new baby was born, how often have you had little interest in doing things?”) (Table 5). The prevalence of postpartum depression varied by age, ranging from 10.3% among women aged 30–39 years to 23.3% among women aged ≤19 years. Prevalence also varied by race/ethnicity: 16.8% among Hispanic women, 11.9% among non-Hispanic white women, and 21.5% among non-Hispanic black women. Among 22 states, the prevalence of postpartum depression ranged from 9.8% in Minnesota to 21.3% in Tennessee (Table 6). ¶¶¶¶ Additional information available at http://www.cdc.gov/nchs/nnhs.htm.

http://www.cdc.gov/nchs/nnhs.htm

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Psychological DistressBoth NHIS and optional modules of BRFSS use the

Kessler-6 scale to identify persons who experienced psycho-logical distress during the 30 days before the survey. NHIS data indicate that in 2009, 3.2% of respondents experienced serious psychological distress (Table 7). BRFSS included the Kessler-6 in the optional mental illness and stigma module dur-ing 2007 (administered in 35 states, the District of Columbia, and Puerto Rico) and 2009 (16 states). Among participating states, prevalence estimates were similar in 2007 (4.0%) and 2009 (3.9%) (Table 8). These BRFSS estimates are higher than NHIS estimates, which might be a result of the limited geographical coverage of BRFSS, differences in survey design and methods, question placement, and context. As in NHIS, women were more likely to have serious psychological distress than men, and rates were highest among adults aged 45–54 years and non-Hispanic blacks. BRFSS data for state-specific prevalences of serious psychological distress during 2007 and 2009 indicate that, like depression, prevalence varied among states, ranging from 1.9% in Utah to 9.4% in Tennessee (Table 9). The prevalence of serious psychological distress was generally highest in the southeastern states (Figure 2).

Mentally Unhealthy DaysThe question on number of mentally unhealthy days is

included in the BRFSS core questionnaire; therefore, data are available for every year for all states and territories. Nationwide, for 2009, adults aged ≥18 years reported an average of 3.5 mentally unhealthy days during the past 30 days (Table 10). Among states, in 2009, the median number of mentally unhealthy days was 3.4, and the 25th and 75th quartiles were 3.1 and 3.7 days, respectively (Table 11). The mean number of mentally unhealthy days was highest in the southeastern states (Figure 3).

Lifetime Diagnosis of Mental IllnessThe BRFSS optional anxiety and depression module includes

questions on whether respondents have received a diagnosis of depression or anxiety disorder in their lifetime. Although the number of participating states varied between the 2 years in which the module was administered, rates of reported lifetime diagnosis of depression were similar in 2006 (15.7%) and 2008 (16.1%) (Tables 12 and 13). The prevalence of lifetime diagnosis of anxiety disorders was slightly lower, with 11.3% in 2006 and 12.3% in 2008 (Tables 14 and 15). In 2007, NHIS included a question for all respondents on lifetime diagnosis of bipolar disorder and schizophrenia; 1.7% of participants had received a diagnosis of bipolar disorder, and 0.6% had received a diagnosis of schizophrenia (Table 16).

National Health-Care SurveysNAMCS and NHAMCS

During 2007–2008, an estimated 47.8 million ambula-tory care visits were made by patients with primary mental health diagnoses, which constituted approximately 5% of all ambulatory care visits made in the United States during those 2 years (Tables 17 and 18). Women made 29.4 million of the visits, compared with 18.5 million for men. Of all mental illness–related visits, the greatest proportion of visits (31%) were made by patients with any depressive disorder, followed by 23% of visits among those with schizophrenia and other psychotic disorders. The proportion of visits related to alco-hol and drug use that occurred in emergency and outpatient departments was higher than the proportion of visits for other mental illness diagnoses.

NHDSAmong patients discharged from nonfederal, short-stay

hospitals, mental illness was a primary diagnosis for 97.9 dis-charged patients per 10,000 population among persons aged 18–64 years. The occurence decreased with age to 64.4 among those aged ≥65 years (Table 19). Mood disorders were the most common primary mental illness discharge diagnosis, and the occurence decreased with age, with a range of 46.0 per 10,000 population among patients aged 18–44 years to 19.2 per 10,000 population among those aged ≥65 years. Alcohol and drug use disorders were the second most common diagnoses and also decreased with age. In contrast to rates for primary diagnoses, discharges rates among patients with mental illness listed as any of the diagnoses increased with age, ranging from 231.4 discharged patients per 10,000 population among those aged 18–44 years to 650.8 per 10,000 population among those aged >65 years (Table 20). As with primary diagnoses of mental illness, mood disorders were the most common diagnosis, fol-lowed by alcohol and drug use disorders.

NNHSThe prevalence of nursing home residents with a primary

diagnosis of mental illness in 2004 increased with age, ranging from 18.7% among those aged 65–74 years to 23.5% among those aged ≥85 years (Table 21). Dementia and Alzheimer disease were the most common primary diagnoses among nursing home residents with a primary diagnosis of mental illness, and the prevalence of each increased with age. Among nursing home residents with any diagnosis of mental illness (among any of 16 current diagnoses), mood disorders and dementia were the most common diagnoses among residents aged 65–74 years and 75–84 years (Table 22). Among residents aged ≥85 years, dementia (41.0%) was the most common

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mental illness, followed by mood disorders (35.3%). In 2004, approximately two thirds of nursing home residents had a diagnosis of a mental illness, and approximately one third of these had a mood disorder.

Discussion CDC national surveillance surveys such as NHANES and

NHIS are important for developing national policies and track-ing progress toward national health goals such as those described in Healthy People 2010 and Healthy People 2020. Data from these surveys are useful for national planning and research.

Two state-based CDC surveys, BRFSS and PRAMS, can provide data at the state or substate levels that can be used for both national and state-level planning. For example, variations in BRFSS estimates for certain mental illnesses might help determine the focus of certain mental health services.

The prevalence of current depression varies substantially by state (from 4.3% in North Dakota to 13.7% in Mississippi and West Virginia), as does the prevalence of serious psycho-logical distress (from 1.9% in Utah to 9.4% in Tennessee). These variations might reflect regional differences, includ-ing demographic characteristics, socioeconomic conditions, availability of and access to health-care services, and patterns of reimbursement for mental health services, that would be useful in planning (52,53). Southeastern states generally have the highest prevalence of depression, serious psychological distress, and mean number of mentally unhealthy days. This finding likely reflects, in part, sociodemographics, access to and use of health care, and the association between mental illness and certain chronic diseases such as obesity, diabetes, and cardiovascular disease (13,14). For some states, BRFSS, PRAMS, and other state-based surveys have provided mental illness data that state and local authorities have used to identify the need for services at the local or regional level.

CDC surveys focus on depression, and they lack sufficient data on anxiety disorders. Anxiety disorders are as common in the population as depression and, like depression and severe psychological distress, can result in high levels of impairment. Moreover, the pathophysiologic characteristics of anxiety disorders are similar to those of depression and often are associated with the same chronic medical conditions (54–56). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), conducted by the National Institute on Alcohol Abuse and Alcoholism, estimated that during 2001–2002, 14% of U.S. adults had an anxiety disorder (7%, specific phobia; 3%, social phobia; 2%, generalized anxiety disorder; and 1%, panic disorder) (23). Estimates from the 2003 National Comorbidity Survey Replication (NCS-R) were

similar, indicating that 18% of adults had an anxiety disorder (9%, specific phobia; 7%, social phobia; 4%, posttraumatic stress disorder; and 3%, panic disorder); 56% of the disorders identified were categorized as serious or moderate (5). Several standardized and validated scales can be used in telephone and in-person interviews to identify and classify anxiety disorders (57,58). Better documentation of the impact of anxiety dis-orders might help guide national public health policy. At the state and local levels, documenting the prevalence and impact of anxiety disorders might help ascertain the need for additional public health services for these disorders.

Although CDC surveys and information systems have provided important information on the prevalence of mental illness, none of them was designed solely to monitor mental illness. They are general surveillance tools that have added components on mental illness gradually over time as recogni-tion of the importance of mental illness in public health has increased. For example, NHANES and NHIS are national CDC surveys designed to monitor the entire range of public health diseases and conditions and can include only a limited number of questions concerning mental illness. Likewise, the state-based CDC BRFSS is designed to provide state and local estimates on a wide range of health behaviors. BRFSS mental illness questions are primarily contained in two small mental illness modules that are optional for states and are not included on the core BRFSS questionnaire administered by all states. States may choose to administer the optional modules, but not all states do so because of financial constraints, competing state surveillance priorities, and limitations in the length of time respondents are willing to spend completing a telephone survey. The willingness of the states to administer optional modules is affected by the rapid rise in the proportion of households that no longer contain a landline telephone (59). Survey calls to cell phone numbers are limited to BRFSS core questions and do not include the optional survey modules, partly because cell phone respondents are not willing to spend as much time completing BRFSS questions as respondents using landline telephones. Recognizing that the number of households with landline telephones will continue to decrease, CDC is exploring additional methods to obtain a valid sample for mental illness questions in BRFSS.

Increasingly, physicians and others who treat mental illness, as well as public health experts, are recognizing the substan-tial overlap between mental illness and diseases traditionally considered to be matters of public health concern. The ability of certain mental illnesses to exacerbate morbidity from sev-eral chronic diseases is well-established. Recent studies have explored the causal pathways from mental illness to certain chronic diseases (60,61), highlighting the need for more accu-rate and timely information on the epidemiology of mental

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illness in the United States. Future mental illness surveillance surveys should measure both depression and anxiety disorders and include more detailed questions concerning their impact on quality of life, associated chronic medical conditions, and issues such as family violence, alcohol and substance abuse, and access to and use of health care. For example, CDC is collaborating with SAMHSA and the Gulf Coast states to conduct surveillance of mental illness in coastal regions affected by the 2010 Deepwater Horizon oil spill. This targeted surveil-lance effort uses standardized questionnaires to identify the occurrence of anxiety disorders, depression, and psychological distress, as well as the effects of mental illness on and use of mental illness services by the Gulf Coast population.

Increased awareness of the value of mental illness surveillance is important, as is identification of gaps in the available CDC data and data from other sources. The impact of psychologi-cal distress and depression is well-documented, and the risk factors and associated issues such as access to and use of health services have been identified. Therefore, increased emphasis should be placed on using this information to initiate public health action and on using surveillance to measure outcomes.

Acknowledgments

This report is based, in part, on contributions by Shilpa Bengeri, Nova Research Company, Hyattsville, Maryland; Janet R. Cummings, PhD, Emory University Rollins School of Public Health, Atlanta, Georgia; Joseph Gfroerer, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland; Elsie Freeman, MD, Maine Department of Health and Human Services, Augusta, Maine; Catherine Simile, PhD, Patricia Barnes, MA, Vladislav Beresovsky, PhD, Yelena Gorina, MPH, MS, Xiang Liu, MS, Susan M. Schappert, MA, Betzaida Tejada-Vera, Anita Bercovitz, PhD, and Jennifer H. Madans, PhD, National Center for Health Statistics, Rosemarie Kobau, MPH, MAPP, Matthew M. Zack, MD, Sherry Farr, PhD, John P. Barile, and Janet B. Croft, PhD, National Center for Chronic Disease Prevention and Health Promotion, Ruth Perou, PhD, National Center for Birth Defects and Developmental Disabilities, James W. Buehler, MD, and JM (Sally) Lin, PhD, Public Health Surveillance Program Office, Hao Tian, PhD, National Center for Emerging and Zoonotic Infectious Diseases, Ileana Arias, PhD, Office of the Director, and Stephen B. Thacker, MD, Office of Surveillance, Epidemiology, and Laboratory Services, CDC.

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http://www.who.int/substance_abuse/terminology/ICD10ClinicalDiagnosis.pdf

http://www.oas.samhsa.gov/nsduh/2k4MRB/2k4spd.pdf

http://www.oas.samhsa.gov/nsduh/2k4MRB/2k4spd.pdf

Supplement


* Patient Health Questionnaire-8 severity score of ≥10.† Quartiles based on point estimates (see Table 4).§ For Arizona, Colorado, Idaho, Illinois, Massachusetts, New York, and Ohio, data

are from 2008.

* Kessler-6 score of ≥13.† For Tennessee and Utah, data are from 2009.§ Quartiles based on point estimates (see Table 9).

FIGURE 1. Prevalence of current depression* among adults aged ≥18 years, by state quartile† — Behavioral Risk Factor Surveillance System, United States, 2006§

FIGURE 2. Prevalence of serious psychological distress* among adults aged ≥18 years, by state quartile† — Behavioral Risk Factor Surveillance System, United States, 2007§

≥9%8% to <9%7% to <8%<7%No data

DCPRVI

≥5%4% to <5%3% to <4%<3%No data

DCPR

FIGURE 3. Mean number of mentally unhealthy days* during past 30 days among adults aged ≥18 years, by state quartile — Behavioral Risk Factor Surveillance System, United States, 2009

≥3.73.4 to <3.73.0 to <3.4<3.0No data

DCGUPRVI

* Survey question: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the last 30 days was your mental health not good?”

Supplement


TABLE 1. CDC surveys and surveillance systems that collect data on mental illness among adults

Name, website, and CDC sponsor Description Method of data

collection Survey topics Mental health topics and questions Population

Behavioral Risk Factor Surveillance System (BRFSS)

http://www.cdc.gov/brfss

Public Health Surveillance Program Office

BRFSS is a state-based system of health surveys that collects information on health-risk behaviors, preventive health practices, and health-care access primarily related to chronic disease and injury. For many states, BRFSS is the only available source of timely, accurate data on health-related behaviors.

Telephone interviews

Heath-risk behaviors

Preventive health practices

Health-care access

Health-related quality of life

Mental illness screening

Disability

Violence

Anxiety and depression module (PHQ-8, lifetime diagnosis of anxiety and depression)

Mental illness and stigma module (K-6, stigma, mental health treatment, and mental illness–related disability)

Health-related quality of life (number of days in past 30 days respondent felt that mental health was not good, felt depressed, felt anxious, felt not getting enough sleep, and felt full of energy)

Life satisfaction

Social support

Smoking, alcohol use, physical activity, and body mass index

Health-care use and access

Sexual and intimate partner violence

National sample of one person (aged ≥18 years) from each household

Approximately 450,000 completed interviews, as of 2010

National Health Interview Survey (NHIS)


National Center for Health Statistics

NHIS is a national survey on the health of the civilian noninstitutionalized U.S. population. The main objective of NHIS is to monitor the health of the U.S. population through the collection and analysis of data on a broad range of health topics.

In-person household interviews

Health status and limitations

Health-care use

Family resources

Health insurance

Health-care access

Vaccination

Injury

Health behaviors

Functioning

Disability

Activity limitations from physical, mental, or emotional problems

External causes and circumstances of injury

Mental health-care use

Mental health conditions and symptoms (in 2007 survey), including ADHD; schizophrenia; bipolar disorder; depression, anxiety, and emotional problems; dementia and senility; mental retardation; learning disabilities; and general distress symptoms

Health-risk behaviors (including tobacco use and alcohol use)

K-6 measure of serious psychological distress

Approximately 40,000 households per year, as of 2010

Oversample of blacks, Hispanics, Asians, and adults aged ≥65 years

National Health and Nutrition Examination Survey (NHANES)

http://www.cdc.gov/nchs/nhanes.htm


NHANES is designed to assess the health and nutritional status of adults and children in the United States. The survey combines interviews and physical examinations.

In-person household interviews

Physical examinations

Laboratory tests

Nutritional assessments

DNA repository

Numerous diseases, medical conditions, and health indicators

Nutrition and nutritional disorders

Environmental risk factors

Health-care use

Mental, behavioral, and emotional problems of children

Weight and physical fitness

Risk factors

Sleep disorders

Alcohol and drug use

Social and emotional support

Use of mental health-care professionals

Activity limitations from poor physical or mental health

PHQ-9 depression screening

Approximately 5,000 persons per year, as of 2008

Oversample of blacks, Mexican-Americans, adolescents, and adults aged ≥60 years

See table footnotes on page 16.

http://www.cdc.gov/brfss


http://www.cdc.gov/nchs/nhanes.htm

Supplement


TABLE 1. (Continued) CDC surveys and surveillance systems that collect data on mental illness among adults



Pregnancy Risk Assessment Monitoring System (PRAMS)


National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health

PRAMS is a surveillance project of CDC and state health departments. PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy.

Mailed surveys with follow-up telephone interviews for nonresponders

Postpartum depressive symptoms

Attitudes and feelings about most recent pregnancy

Prenatal care

Maternal alcohol and tobacco use

HIV testing

Health insurance coverage

Physical abuse before and during pregnancy

Pregnancy-related morbidity

Infant health care

Contraceptive use

Breastfeeding practices

Health-care provider advice

Whether health-care provider discussed with respondent healthy and risky pregnancy behaviors (including drinking alcohol and smoking during pregnancy)

Maternal tobacco and alcohol use before, during, and after pregnancy

Difficult or traumatic events before or during pregnancy

Pregnancy intention, both of mother and of partner

Whether respondent needed and received counseling for substance use or personal problems during or after pregnancy

Interpersonal violence before and during pregnancy

Injury control and prevention

Social support and stress

Infant sleeping behaviors

Infant and maternal exposure to smoke

Feelings, diagnosis, and treatment of postpartum depression, hopelessness, and anxiety

Approximately 50,000 women with live-born infants per year, as of 2008

National Ambulatory Medical Care Survey (NAMCS)



NAMCS is a national survey that collects data on the provision and use of ambulatory medical care services in the United States. Findings are based on a sample of visits to nonfederal, employed, office-based physicians who are primarily engaged in direct patient care.

Patient record forms completed by physicians and staff members or survey field representatives

Demographic characteristics of patients

Expected payment sources

Patients’ principal complaints, symptoms, or other reasons for visit

Physician diagnoses, diagnostic and screening services

Medications

Types of health-care providers seen during visit

Disposition

Causes of injury (if applicable)

Current diagnosed mental health conditions

Current depression

Cause of injury (including intentional)

Health education services ordered or provided at visit (including injury prevention, stress management, and tobacco use and exposure)

Nonmedication treatment provided at visit (including psychotherapy and mental health counseling)

Type of health-care providers patient visited or was referred to during visit (including providers of mental health services)

Medications

Office-based physicians and then visits within the practices. In 2007, data were provided on 32,778 visits.

See table footnotes on page 16.



Supplement


TABLE 1. (Continued) CDC surveys and surveillance systems that collect data on mental illness among adults



National Hospital Ambulatory Medical Care Survey (NHAMCS)



NHAMCS is designed to collect data on the use and provision of ambulatory care services in hospital emergency and outpatient departments. Findings are based on a national sample of visits to the emergency departments and outpatient departments of noninstitutional general and short-stay hospitals.

Patient record forms completed by hospital physicians and staff members


Expected payment sources


Physician diagnoses, diagnostic and screening services

Procedures (emergency department only)

Medications

Disposition

Types of health- care providers seen during visit

Causes of injury (if applicable)

Emergency department:


Causes of injury (including intentional)

Health-care provider diagnoses

Medications

Mental health providers seen during visit

Transfer to psychiatric hospital

Admission to mental health or detoxification unit

Outpatient department:

Current diagnosed mental health conditions

Current depression

Cause of injury (including intentional)

Health education services ordered or provided at visit (including injury prevention, stress management, and tobacco use and exposure)

Nonmedication treatment provided at visit (including psychotherapy and mental health counseling)

Type of health-care providers patient visited or was referred to during visit (including providers of mental health services)

Medications

Nationally representative sample of 500 nonfederal short-stay (<30 days) hospitals

National Hospital Discharge Survey (NHDS)



NHDS is a national probability survey of characteristics of inpatients discharged from nonfederal short-stay hospitals in the United States.

Medical record abstraction


Expected sources of payment

Type and source of admission

Disposition

Discharge diagnoses (up to seven)

Surgical and diagnostic procedures (up to four)

Discharge diagnoses (up to seven)

Surgical and diagnostic procedures (up to four)

Nationally representative sample of nonfederal short-stay hospitals and systematic samples of discharges within hospitals

National Nursing Home Survey (NNHS)



NNHS is a continuing series of national sample surveys of nursing homes and their residents and staff members.

Interviews with staff member best acquainted with resident medical records


Admitting diagnosis

Current diagnoses (up to 16)

Health status

Activities of daily living

Vision and hearing

Continence

Pain assessment

Behavior

Mood

Medications

Falls

Services received

Sources of payment

Behavioral problems

Depressed mood

Medications

Admitting diagnosis

Current diagnoses (up to 16)

Current assignment to specialty unit (i.e., dementia or behavioral health)

Decision-making ability

Sample of nursing homes (that had at least three beds and were either certified by Medicare or Medicaid or had a state license to operate as a nursing home) and then sample of residents within nursing homes

Abbreviations: ADHD = attention deficit hyperactivity disorder; HIV = human immunodeficiency virus; K-6 = Kessler-6; PHQ-8 = Patient Health Questionnaire-8; PHQ-9 = Patient Health Questionnaire-9.




Supplement


TABLE 2. Prevalence of depression* among adults aged ≥18 years, by sociodemographic characteristics — National Health and Nutrition Examination Survey, United States, 2005–2008

Characteristic No. % (95% CI)

Total 10,279 6.8 (5.8–7.8)Sex

Male 6,240 4.9 (3.9–5.9) Female 6,397 8.4 (7.4–9.4)

Age group (yrs) 18–39 4,093 6.2 (5.2–7.2) 40–59 2,992 8.4 (6.8–10.0) ≥60 3,194 5.2 (4.0–6.4)Race/Ethnicity

Mexican-American 1,983 7.2 (5.6–8.8)Black, non-Hispanic 2,273 9.7 (7.9–11.5)White, non-Hispanic 4,882 6.2 (5.0–7.4)

Abbreviation: CI = confidence interval.* Patient Health Questionnaire-9 score of ≥10.

TABLE 3. Prevalence of current depression* among adults aged ≥18 years, by sociodemographic characteristics and year — Behavioral Risk Factor Surveillance System, multiple states, 2006 and 2008

Characteristic

2006† 2008§

No. % (95% CI) No. % (95% CI)

Total 198,678 8.7 (8.4–9.0) 85,004 8.2 (7.8–8.6)Sex

Male 76,288 6.8 (6.4–7.3) 32,243 6.6 (6.1–7.2)Female 122,390 10.5 (10.1–10.9) 52,761 9.8 (9.2–10.3)

Age group (yrs) 18–24 9,186 10.9 (9.7–12.2) 2,963 10.2 (8.5–12.2) 25–34 24,493 8.7 (8.0–9.4) 8,327 8.3 (7.3–9.4) 35–44 34,910 8.8 (8.2–9.4) 12,967 8.3 (7.5–9.3) 45–54 42,321 9.9 (9.3–10.5) 18,071 10.2 (9.4–11.1) ≥55 86,396 6.9 (6.5–7.3) 42,071 6.1 (5.7–6.6)Race/Ethnicity

White, non-Hispanic 153,642 8.0 (7.7–8.3) 68,695 7.5 (7.1–7.9)Black, non-Hispanic 15,819 11.0 (10.1–12.1) 4,837 12.7 (11.1–14.6)Other, non-Hispanic¶ 11,955 10.4 (9.3–11.7) 6,258 9.4 (7.9–11.2)Hispanic 15,602 9.9 (8.9–11.0) 4,458 9.5 (7.9–11.3)

Abbreviation: CI = confidence interval.* Patient Health Questionnaire-8 depression severity score of ≥10.† Data from 38 states, District of Columbia, Puerto Rico, and U.S. Virgin Islands.§ Data from 16 states.¶ Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

Supplement


TABLE 4. Prevalence of current depression* among adults aged ≥18 years, by state/area and year — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

State/Area

2006 2008

No. % (95% CI) No. % (95% CI)

Alabama 2,758 12.5 (10.4–15.0) — — —Alaska 1,806 6.7 (5.4–8.2) — — —Arizona —† — — 5,314 9.7 (8.0–11.7)Arkansas 4,809 12.2 (11.0–13.4) — — —California 5,177 8.8 (7.8–9.9) — — —Colorado — — — 5,093 7.0 (6.0–8.1)Connecticut 4,109 5.9 (5.0–6.9) — — —Delaware 3,780 8.2 (6.9 – 9.6) — — —District of Columbia 3,485 7.9 (6.6–9.4) — — —Florida 9,298 8.9 (7.9–9.9) — — —Georgia 6,485 8.2 (7.3–9.2) — — —Hawaii 5,840 7.2 (6.3–8.1) 5,901 7.4 (6.5–8.5)Idaho — — — 4,570 7.6 (6.6–8.7)Illinois — — — 4,879 8.4 (7.4–9.6)Indiana 5,746 9.6 (8.7–10.7) — — —Iowa 4,692 5.8 (5.0–6.7) — — —Kansas 3,797 6.9 (5.9–8.1) 3,783 8.6 (7.4–9.9)Louisiana 5,774 9.5 (8.5–10.5) 5,388 9.3 (8.3–10.4)Maine 3,605 7.4 (6.4–8.6) 3,724 7.8 (6.8–9.0)Maryland 4,261 7.5 (6.3–8.8)Massachusetts — — — 5,835 7.1 (6.2–8.2)Michigan 5,077 10.5 (9.4–11.8) — — —Minnesota 4,119 6.2 (5.4–7.2) — — —Mississippi 5,225 13.0 (11.8–14.2) 6,387 13.7 (12.5–15.0)Missouri 4,771 9.4 (8.3–10.7) — — —Montana 5,262 6.7 (5.8–7.6) — — —Nebraska 3,516 5.6 (4.6–6.9) 4,840 8.5 (6.9–10.3)Nevada 3,222 9.0 (7.5–10.7) — — —New Hampshire 5,230 6.8 (6.0–7.8) — — —New Mexico 5,745 9.3 (8.3–10.5) — — —New York — — — 3,444 7.3 (6.3–8.4)North Dakota 4,164 5.3 (4.4–6.2) 4,482 4.3 (3.6–5.1)Ohio — — — 5,797 9.2 (8.2–10.4)Oklahoma 6,117 11.5 (10.5–12.6) — — —Oregon 4,294 7.6 (6.6–8.7) — — —Rhode Island 4,002 8.6 (7.4–9.9) — — —South Carolina 7,853 8.8 (8.0–9.7) — — —Tennessee 3,860 10.3 (9.0–11.8) — — —Texas 5,856 8.5 (7.3–9.9) — — —Utah 4,621 8.7 (7.5–10.0) — — —Vermont 6,297 7.1 (6.3–8.0) 6,185 7.8 (6.9–8.7)Virginia 4,636 7.3 (6.0–8.9) — — —Washington 10,397 6.4 (5.8–7.1) 9,382 7.4 (6.7–8.2)West Virginia 3,439 13.7 (12.3–15.2) — — —Wisconsin 4,228 6.7 (5.7–7.8) — — —Wyoming 4,495 7.3 (6.4–8.3) — — —Puerto Rico 4,181 11.2 (10.1–12.3) — — —U.S. Virgin Islands 2,649 7.1 (6.0–8.5) — — —

Abbreviation: CI = confidence interval.* Patient Health Questionnaire-8 depression severity score of ≥10.† Not measured.

Supplement


TABLE 5. Prevalence of postpartum depressive symptoms, by sociodemographic characteristics and symptoms — Pregnancy Risk Assessment Monitoring System, United States, multiple sites, 2004–2008*

Characteristic

Self-reported symptoms†

Down, depressed, or hopeless Little interest or pleasure in doing things Either or both symptoms§

No. % (95% CI) No. % (95% CI) No. % (95% CI)

Total 138,113 9.5 (9.2– 9.7) 137,979 9.8 (9.5–10.0) 137,461 14.5 (14.2–14.8)Age group (yrs) ≤19 13,266 14.3 (13.2–15.4) 13,251 15.5 (14.3–16.7) 13,209 23.3 (21.9–24.7) 20–29 70,749 10.5 (10.1–10.9) 70,699 10.6 (10.2–11.1) 70,433 15.8 (15.3–16.3) 30–39 49,724 6.7 (6.4– 7.1) 49,648 7.0 (6.6– 7.4) 49,465 10.3 (9.9–10.8) ≥40 4,365 7.5 (6.3– 8.9) 4,372 8.2 (6.9– 9.8) 4,345 12.1 (10.5–13.9)Race/Ethnicity

Hispanic 20,847 9.9 (9.2–10.6) 20,729 11.8 (11.0–12.6) 20,632 16.8 (15.9–17.7)White, non-Hispanic 73,272 8.8 (8.5– 9.1) 73,362 7.5 (7.2– 7.9) 73,106 11.9 (11.6–12.3)Black, non-Hispanic 20,307 12.1 (11.3–13.0) 20,219 15.9 (14.9–16.8) 20,184 21.5 (20.5–22.6)Other 22,803 9.3 (8.5–10.2) 22,783 14.5 (13.5–15.6) 22,659 19.7 (18.5–20.9)

Abbreviation: CI = confidence interval.* New York state excludes New York City, which conducts a separate survey. 2004: Alaska, Colorado, Georgia, Hawaii, Maine, Maryland, Minnesota, Nebraska, New

Mexico, New York, North Carolina, Oregon, Rhode Island, South Carolina, Utah, Vermont, and Washington; 2005: Alaska, Colorado, Georgia, Hawaii, Maine, Maryland, Minnesota, Nebraska, New Mexico, New York, North Carolina, Ohio, Oregon, Rhode Island, South Carolina, Utah, Vermont, and Washington; 2006: Alaska, Colorado, Georgia, Hawaii, Maine, Maryland, Minnesota, Nebraska, New York, Ohio, Oregon, Rhode Island, South Carolina, Utah, Vermont, and Washington; 2007: Alaska, Colorado, Delaware, Georgia, Hawaii, Maine, Maryland, Massachusetts, Minnesota, Missouri, Nebraska, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota Tribal, Utah, Vermont, Washington, Wisconsin, and Wyoming; 2008: Alaska, Colorado, Delaware, Georgia, Hawaii, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Washington, Wisconsin, and Wyoming.

† Survey questions: “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and “Since your new baby was born, how often have you had little interest or little pleasure in doing things?” Possible responses are “never,” “rarely,” “sometimes,” “often,” and “always.” Women who answered “often” or “always” were categorized as having symptoms of postpartum depression.

§ Women who answered “often” or “always” to either question or both questions.

TABLE 6. Prevalence of postpartum depressive symptoms, by state and symptoms — Pregnancy Risk Assessment Monitoring System, 22 states, 2008

State

Self-reported symptoms*

Down, depressed, or hopelessLittle interest or pleasure

in doing things Either or both symptoms†

% (95% CI) % (95% CI) % (95% CI)

Alaska 8.0 (6.3–10.1) 9.1 (7.3–11.2) 13.2 (11.0–15.7)Colorado 7.9 (6.5–9.6) 9.5 (7.9–11.4) 13.5 (11.6–15.6)Delaware 8.8 (7.3–10.5) 9.0 (7.5–10.8) 14.4 (12.6–16.6)Georgia 9.5 (7.0–12.8) 9.0 (6.6–12.2) 12.8 (9.9–16.5)Hawaii 7.9 (6.7–9.4) 10.2 (8.8–11.7) 14.7 (13.1–16.5)Maine 10.3 (8.4–12.6) 8.4 (6.7–10.5) 12.6 (10.5–15.1)Maryland 8.9 (7.0–11.3) 8.6 (6.7–10.9) 13.5 (11.1–16.3)Massachusetts 7.9 (6.3–9.9) 8.8 (7.3–10.6) 12.9 (10.9–15.1)Minnesota 6.7 (5.4–8.3) 6.4 (5.1–7.9) 9.8 (8.3–11.6)Nebraska 7.4 (5.9–9.1) 6.8 (5.5–8.4) 10.8 (9.1–12.8)New York 7.5 (5.8–9.7) 9.4 (7.4–11.8) 12.7 (10.4–15.4)North Carolina 10.0 (8.3–12.0) 9.2 (7.6–11.1) 14.2 (12.2–16.4)Ohio 11.2 (9.2–13.6) 10.9 (9.0–13.3) 16.4 (14.0–19.1)Oregon 9.0 (7.0–11.5) 7.4 (5.7–9.6) 12.3 (10.0–15.0)Pennsylvania 7.3 (5.8–9.3) 8.8 (7.1–10.9) 12.0 (10.0–14.3)Rhode Island 9.1 (7.4–11.2) 10.1 (8.3–12.2) 13.9 (11.8–16.3)Tennessee 15.0 (11.9–18.7) 12.3 (9.5–15.7) 21.3 (17.7–25.4)Utah 8.5 (7.2–10.0) 8.3 (7.1–9.8) 12.6 (11.0–14.3)Vermont 8.7 (7.2–10.6) 6.9 (5.5–8.6) 11.7 (9.8–13.8)Washington 8.9 (7.1–11.0) 9.6 (7.8–11.7) 13.8 (11.6–16.2)Wisconsin 7.8 (6.2–9.9) 9.4 (7.5–11.6) 13.8 (11.6–16.3)Wyoming 8.1 (6.3–10.4) 8.2 (6.3–10.6) 12.0 (9.7–14.7)Total 9.1 (8.5–9.7) 9.2 (8.7–9.8) 13.7 (13.1–14.4)

Abbreviation: CI = confidence interval.* Survey questions: “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and “Since your new baby was born, how often have you

had little interest or little pleasure in doing things?” Possible responses are “never,” “rarely,” “sometimes,” “often,” and “always.” Women who answered “often” or “always” were categorized as having symptoms of postpartum depression.

† Women who answered “often” or “always” to either question or both questions

Supplement


TABLE 7. Prevalence of serious psychological distress* among adults aged ≥18 years, by sociodemographic characteristics — National Health Interview Survey, United States, 2009

Characteristic No. % (95% CI)

Total 27,858 3.2 (2.9–3.5)Sex

Male 12,322 2.8 (2.4–3.2)Female 15,536 3.7 (3.3–4.1)

Age group (yrs) <45 12,846 3.3 (2.9–3.7) 45–64 9,503 3.7 (3.2–4.2) ≥65 5,509 2.1 (1.6–2.6)Race/Ethnicity

Hispanic 5,196 3.4 (2.9–4.0)Black, non-Hispanic 4,374 3.8 (3.0–4.7)White, non-Hispanic 16,187 3.2 (2.8–3.6)

Abbreviation: CI = confidence interval.*Kessler-6 score of ≥13.

TABLE 8. Prevalence of serious psychological distress* among adults aged ≥18 years, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2007 and 2009

Characteristic

2007† 2009§

No. % (95% CI) No. % (95% CI)

Total 203,096 4.0 (3.8–4.1) 87,992 3.9 (3.6–4.3)Sex

Male 75,450 3.5 (3.3–3.9) 33,434 3.5 (3.0–4.0)Female 127,646 4.3 (4.1–4.6) 54,558 4.4 (4.0–4.8)


White, non-Hispanic 158,774 3.4 (3.2–3.5) 68,335 3.5 (3.2–3.9)Black, non-Hispanic 14,364 6.1 (5.1–7.2) 8,410 5.4 (4.5–6.4)Other, non-Hispanic¶ 12,700 4.0 (3.3–4.7) 6,507 3.1 (2.3–4.1)Hispanic 15,552 5.5 (4.8–6.3) 3,886 5.3 (4.2–6.7)

*Kessler-6 score of ≥13.† Data from 35 states, District of Columbia, and Puerto Rico.§ Data from 16 states. ¶Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

Supplement


TABLE 9. Prevalence of serious psychological distress* among adults aged ≥18 years, by state/area — Behavioral Risk Factor Surveillance System, United States, 2007 and 2009

State/Area

2007 2009

No. % (95% CI) No. % (95% CI)

Alaska 2,329 2.4 (1.5–3.9) —† — —Arkansas 5,242 5.1 (4.4–6.0) — — —California 5,169 3.5 (2.9–4.3) 4,784 3.7 (3.0–4.4)Colorado 5,460 3.2 (2.6–3.9) — — —District of Columbia 3,545 2.6 (2.0–3.4) — — —Georgia 6,872 5.0 (4.2–5.9) 5,243 3.1 (2.5–3.9)Hawaii 6,288 2.4 (1.9–3.0) 6,204 2.4 (1.9–2.9)Illinois 5,043 3.0 (2.5–3.7) — — —Indiana 5,473 3.5 (2.9–4.1) — — —Iowa 4,891 2.3 (1.8–2.8) — — —Kansas 4,034 2.6 (2.0–3.3) 8,617 2.5 (2.1–3.0)Kentucky 6,049 6.5 (5.6–7.4) — — —Louisiana 5,865 5.3 (4.6–6.1) — — —Maine 3,884 3.8 (3.1–4.7) — — —Massachusetts 4,394 3.1 (2.4–3.9) 4,738 3.3 (2.6–4.2)Michigan 4,194 3.8 (3.1–4.7) 2,779 3.5 (2.6–4.6)Minnesota 4,716 2.7 (2.1–3.4)Mississippi 7,173 6.6 (5.8–7.5) 10,113 7.1 (6.3–7.9)Missouri 4,842 5.0 (4.2–6.0) 4,555 4.5 (3.6–5.7)Montana 5,628 3.5 (2.9–4.2)Nebraska 5,103 2.5 (1.9–3.3) 4,933 2.6 (1.9–3.7)Nevada 3,858 4.0 (3.2–5.1) 3,536 4.0 (3.0–5.1)New Hampshire 5,613 3.2 (2.7–3.8) — — —New Mexico 5,972 4.1 (3.4–4.8) — — —Ohio 5,065 4.6 (3.8–5.5) — — —Oklahoma 6,793 5.3 (4.6–6.1) — — —Oregon 1,875 2.9 (2.2–3.8) — — —Rhode Island 3,976 4.7 (3.9–5.6) — — —South Carolina 9,583 5.0 (4.3–5.8) 8,843 4.4 (3.8–5.2)Tennessee — — — 2,216 9.4 (7.7–11.6)Texas 7,673 5.2 (4.3–6.2)Utah — — — 2,446 1.9 (1.4–2.6)Vermont 6,592 3.3 (2.7–4.2) 6,278 3.1 (2.5–3.7)Virginia 5,689 3.3 (2.7–4.0) — — —Washington 13,317 2.9 (2.5–3.4) 7,062 2.9 (2.4–3.5)Wisconsin 4,538 2.7 (2.1–3.4) — — —Wyoming 5,738 3.2 (2.6–3.9) 5,645 2.6 (1.9–3.4)Puerto Rico 3,776 6.0 (5.2–7.0) — — —

Abbreviation: CI = confidence interval.* Kessler-6 score of ≥13.† Not measured.

Supplement


TABLE 10. Mean number of mentally unhealthy days* during past 30 days among adults aged ≥18 years, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2009†

CharacteristicNo. of

respondents

Mean no. of mentally

unhealthy days (95% CI)

Total 424,218 3.5 (3.4–3.6)Sex

Male 161,046 2.9 (2.8–3.1)Female 263,172 4.0 (3.9–4.1)

Age group (yrs) 18–24 13,032 3.9 (3.6–4.2) 25–34 36,755 3.8 (3.6–4.0) 35–44 59,253 3.7 (3.6–3.9) 45–54 85,446 3.9 (3.8–4.1) ≥55 226,168 2.8 (2.7–2.9)Race/Ethnicity

White, non-Hispanic 333,119 3.3 (3.2–3.4)Black, non-Hispanic 33,741 4.1 (3.9–4.4)Other, non-Hispanic§ 23,549 3.6 (3.3–3.8)Hispanic 29,361 3.8 (3.6–4.1)

Abbreviation: CI = confidence interval.* Survey question: “Now thinking about your mental health, which includes

stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”

† Data from 50 states, Guam, Puerto Rico, and U.S. Virgin Islands. Only includes respondents interviewed in 2009.

§ Asian, Native Hawaiian/ Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

TABLE 11. Mean number of mentally unhealthy days* during past 30 days among adults aged ≥18 years, by state/area — Behavioral Risk Factor Surveillance System, United States, 2009

State/AreaNo. of

respondents†

Mean no. of mentally

unhealthy days (95% CI)

Alabama 6,616 4.2 (3.8–4.5)Alaska 2,363 2.5 (2.1–3.0)Arizona 5,403 3.4 (3.0–3.9)Arkansas 3,904 3.6 (3.2–4.0)California 17,316 3.7 (3.5–3.9)Colorado 11,768 3.1 (2.9–3.4)Connecticut 6,414 3.1 (2.8–3.4)Delaware 4,315 3.1 (2.8–3.5)District of Columbia 3,844 2.7 (2.4–3.0)Florida 11,753 3.5 (3.2–3.8)Georgia 5,761 2.8 (2.5–3.1)Hawaii 6,642 2.6 (2.3–2.9)Idaho 5,315 3.2 (2.9–3.5)Illinois 5,819 3.5 (3.2–3.8)Indiana 9,094 3.8 (3.5–4.1)Iowa 5,941 2.6 (2.4–2.9)Kansas 18,702 2.9 (2.7–3.1)Kentucky 9,536 4.6 (4.2–5.0)Louisiana 8,765 3.5 (3.2–3.8)Maine 7,942 3.4 (3.2–3.7)Maryland 8,440 3.3 (3.0–3.6)Massachusetts 16,397 3.2 (2.9–3.4)Michigan 9,103 3.7 (3.4–4.0)Minnesota 5,583 2.8 (2.5–3.1)Mississippi 10,997 4.1 (3.8–4.4)Missouri 5,000 3.9 (3.5–4.3)Montana 7,506 3.3 (3.0–3.6)Nebraska 15,733 2.6 (2.4–2.9)Nevada 3,791 4.0 (3.5–4.6)New Hampshire 5,931 3.1 (2.8–3.4)New Jersey 12,025 3.3 (3.0–3.6)New Mexico 8,715 3.5 (3.2–3.8)New York 6,786 3.5 (3.1–3.8)North Carolina 13,068 3.8 (3.5–4.1)North Dakota 4,698 2.4 (2.1–2.7)Ohio 9,650 3.8 (3.5–4.1)Oklahoma 7,724 4.3 (3.9–4.6)Oregon 4,238 3.2 (2.8–3.6)Pennsylvania 9,003 3.6 (3.3–3.9)Rhode Island 6,223 3.4 (3.1–3.8)South Carolina 9,568 3.5 (3.2–3.8)South Dakota 6,739 2.4 (2.1–2.7)Tennessee 5,510 3.8 (3.4–4.2)Texas 11,381 3.6 (3.3–3.9)Utah 9,997 3.3 (3.0–3.5)Vermont 6,563 3.3 (3.1–3.6)Virginia 5,078 3.4 (2.9–3.8)Washington 20,018 3.3 (3.1–3.5)West Virginia 4,761 4.1 (3.8–4.5)Wisconsin 4,517 2.9 (2.5–3.2)Wyoming 5,965 3.2 (2.8–3.5)Guam 1,247 2.1 (1.6–2.5)Puerto Rico 4,136 3.2 (2.8–3.5)U.S. Virgin Islands 2,414 2.9 (2.4–3.3)

Abbreviation: CI = confidence interval.* Survey question: “Now thinking about your mental health, which includes

stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”

† Only includes respondents interviewed in 2009.

Supplement


TABLE 12. Percentage of adults aged ≥18 years who ever received a diagnosis of depression in their lifetime, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

Characteristic

2006* 2008†

No. % (95% CI) No. % (95% CI)

Total 215,576 15.7 (15.4–16.1) 91,377 16.1 (15.6–16.6)Sex

Male 82,284 11.1 (10.6–11.5) 34,481 11.2 (10.6–11.9)Female 133,292 20.2 (19.7–20.6) 56,896 20.7 (20.0–21.3)


White, non-Hispanic 165,506 17.2 (16.8–17.6) 73,604 17.3 (16.8–17.8)Black, non-Hispanic 17,650 11.2 (10.4–12.0) 5,280 12.3 (10.7–14.0)Other, non-Hispanic§ 13,245 15.1 (13.7–16.6) 6,783 12.2 (10.5–14.1)Hispanic 17,044 12.6 (11.6–13.7) 4,807 12.8 (11.1–14.7)

Abbreviation: CI = confidence interval.* Data from 38 states, District of Columbia, Puerto Rico, and U.S. Virgin Islands† Data from 16 states. § Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

Supplement


TABLE 13. Percentage of adults aged ≥18 years who ever received a diagnosis of depression in their lifetime, by state/area — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

State/Area

2006 2008

No. % (95% CI) No. % (95% CI)

Alabama 3,111 17.4 (15.8–19.2) —* — —Alaska 1,998 17.4 (15.4–19.7) — — —Arizona — — — 5,768 18.1 (16.1–20.4)Arkansas 5,288 21.3 (19.9–22.7) — — —California 5,284 13.5 (12.4–14.7) — — —Colorado 5,463 17.7 (16.4–19.0)Connecticut 4,446 14.3 (13.0–15.8) — — —Delaware 3,941 17.0 (15.2–18.9) — — —District of Columbia 3,754 15.0 (13.5–16.6) — — —Florida 10,232 13.1 (12.2–14.2) — — —Georgia 6,992 14.5 (13.4–15.6) — — —Hawaii 6,229 8.8 (8.0–9.8) 6,218 9.8 (8.9–10.8)Idaho — — — 4,893 18.9 (17.4–20.4)Illinois — — — 5,047 13.5 (12.4–14.7)Indiana 6,208 19.8 (18.6–21.1) — — —Iowa 5,164 14.7 (13.5–15.9) — — —Kansas 4,109 14.1 (12.8–15.6) 4,125 13.5 (12.2–14.8)Louisiana 6,725 13.2 (12.3–14.2) 5,893 12.4 (11.4–13.4)Maine 3,864 19.9 (18.5–21.5) 3,981 20.9 (19.3–22.6)Maryland 4,577 15.4 (13.9–17.1)Massachusetts — — — 6,326 15.3 (14.0–16.7)Michigan 5,484 15.9 (14.7–17.0) — — —Minnesota 4,232 14.4 (13.2–15.8) — — —Mississippi 5,828 16.9 (15.7–18.2) 6,990 16.8 (15.7–18.1)Missouri 5,045 18.4 (16.8–20.1) — — —Montana 5,733 17.1 (15.9–18.4) — — —Nebraska 3,851 15.5 (13.8–17.3) 5,221 16.9 (15.0–19.1)Nevada 3,442 15.5 (13.9–17.3) — — —New Hampshire 5,592 17.2 (16.0–18.6) — — —New Mexico 6,146 17.1 (16.0–18.3) — — —New York — — — 3,692 15.5 (14.2–16.9)North Carolina — — —North Dakota 4,566 16.8 (15.4–18.4) 4,865 15.0 (13.6–16.4)Ohio 6,230 19.5 (18.1–20.9)Oklahoma 6,786 19.9 (18.7–21.1) — — —Oregon 4,670 21.3 (19.9–22.7) — — —Rhode Island 4,267 16.8 (15.3–18.4) — — —South Carolina 8,703 17.3 (16.3–18.4) — — —Tennessee 4,172 16.4 (14.8–18.0) — — —Texas 6,395 15.4 (13.9–17.0) — — —Utah 4,983 19.6 (18.1–21.2) — — —Vermont 6,794 20.2 (19.1–21.4) 6,586 21.4 (20.2–22.7)Virginia 5,133 15.1 (13.7–16.7) — — —Washington 11,301 20.1 (19.1–21.1) 10,079 17.2 (16.2–18.1)West Virginia 3,725 20.2 (18.7–21.7) — — —Wisconsin 4,375 16.4 (15.0–17.8) — — —Wyoming 4,818 18.2 (17.0–19.5) — — —Puerto Rico 4,588 18.1 (16.9–19.5) — — —U.S. Virgin Islands 3,025 6.8 (5.8–7.9) — — —

Abbreviation: CI = confidence interval.* Not measured.

Supplement


TABLE 14. Percentage of adults aged ≥18 years who ever received a diagnosis of anxiety in their lifetime, by sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

2006* 2008†

Characteristic No. % (95% CI) No. % (95% CI)

Total 215,522 11.3 (11.0–11.6) 91,339 12.3 (11.8–12.7)Sex

Male 82,288 8.2 (7.8–8.7) 34,447 9.1 (8.5–9.7)Female 133,234 14.3 (13.9–14.6) 56,892 15.2 (14.6–15.9)


White, non-Hispanic 165,498 12.2 (11.9–12.5) 73,577 12.9 (12.5–13.4)Black, non-Hispanic 17,634 8.6 (7.8–9.4) 5,270 9.3 (7.9–10.8)Other, non-Hispanic§ 13,231 12.0 (10.6–13.7) 6,781 11.8 (9.9–13.9)Hispanic 17,041 9.0 (8.2–9.8) 4,806 9.7 (8.2–11.3)

Abbreviation: CI = confidence interval.* Data from 38 states, District of Columbia, Puerto Rico, and U.S. Virgin Islands.† Data from 16 states.§ Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

Supplement


TABLE 15. Percentage of adults aged ≥18 years who ever received a diagnosis of anxiety in their lifetime, by state/area — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008

State/Area

2006 2008

No. % (95% CI) No. % (95% CI)

Alabama 3,107 14.0 (12.5–15.7) —* — —Alaska 2,000 12.0 (10.2–14.1) — — —Arizona 14.0 (12.8–15.2) 5,777 13.0 (11.2–15.1)Arkansas 5,285 — — —California 5,283 9.6 (8.6–10.7) — — —Colorado 5,462 12.3 (11.1–13.5)Connecticut 4,451 10.0 (8.9–11.3) — — —Delaware 3,935 12.1 (10.5–13.9) — — —District of Columbia 3,758 9.5 (8.3–10.9) — — —Florida 10,241 11.2 (10.3–12.2) — — —Georgia 6,997 11.1 (10.1–12.1) — — —Hawaii 6,222 8.0 (7.2–8.9) 6,212 8.3 (7.4–9.2)Idaho — — — 4,896 11.6 (10.4–12.9)Illinois — — — 5,044 10.8 (9.7–12.0)Indiana 6,209 13.8 (12.7–15.0) — — —Iowa 5,173 9.1 (8.2–10.1) — — —Kansas 4,110 9.9 (8.8–11.2) 4,128 10.4 (9.2–11.7)Louisiana 6,719 10.9 (10.0–11.8) 5,896 11.5 (10.5–12.6)Maine 3,863 16.1 (14.5–17.7) 3,986 16.7 (15.2–18.4)Maryland 4,582 10.9 (9.6–12.4)Massachusetts — — — 6,289 13.9 (12.6–15.2)Michigan 5,487 11.1 (10.1–12.1) — — —Minnesota 4,232 10.1 (9.1–11.3) — — —Mississippi 5,808 13.7 (12.6–14.8) 6,984 13.1 (12.1–14.3)Missouri 5,044 12.5 (11.0–14.3) — — —Montana 5,735 10.9 (9.8–12.0) — — —Nebraska 3,850 9.8 (8.4–11.4) 5,223 10.6 (8.9–12.5)Nevada 3,434 11.6 (10.2–13.2) — — —New Hampshire 5,604 12.8 (11.7–14.0) — — —New Jersey — — — — — —New Mexico 6,155 12.0 (11.0–13.1) — — —New York — — — 3,692 12.2 (11.0–13.5)North Dakota 4,564 10.2 (9.0–11.6) 4,868 10.7 (9.4–12.1)Ohio — — — 6,226 13.8 (12.6–15.2)Oklahoma 6,775 14.8 (13.8–15.9) — — —Oregon 4,667 13.2 (12.1–14.5) — — —Rhode Island 4,266 13.2 (12.0–14.6) — — —South Carolina 8,694 12.9 (12.0–13.8) — — —Tennessee 4,171 12.2 (10.7–13.8) — — —Texas 6,386 10.3 (9.1–11.8) — — —Utah 4,982 12.6 (11.4–14.0) — — —Vermont 6,782 14.2 (13.2–15.2) 6,579 14.6 (13.6–15.7)Virginia 5,135 10.7 (9.5–12.1) — — —Washington 11,285 12.9 (12.0–13.8) 10,077 11.8 (11.0–12.7)West Virginia 3,717 17.2 (15.8–18.7) — — —Wisconsin 4,377 10.2 (9.1–11.5) — — —Wyoming 4,815 10.6 (9.6–11.7) — — —Puerto Rico 4,594 14.8 (13.6–16.0) — — —U.S. Virgin Islands 3,028 5.4 (4.6–6.4) — — —

Abbreviation: CI = confidence interval.* Not measured.

Supplement


TABLE 16. Percentage of adults aged ≥18 years who ever received a diagnosis of bipolar disorder or schizophrenia,* by sociodemographic characteristics — National Health Interview Survey, United States, 2007

Frequency

Bipolar disorder Schizophrenia

% (SE) % (SE)

Total 23,354 1.7 (0.1) 0.6 (0.1)Sex

Male 10,356 1.4 (0.1) 0.8 (0.2)Female 12,998 1.9 (0.2) 0.4 (0.1)

Age group (yrs) 18–39 8,852 2.2 (0.2) 0.6 (0.2) 40–54 6,529 1.9 (0.2) 0.7 (0.1) ≥55 7,973 0.8 (0.1) 0.5 (0.1)Race/Ethnicity

Hispanic 4,191 0.9 (0.2) 0.5 (0.1)White, non-Hispanic 14,030 1.9 (0.1) 0.6 (0.1)Black, non-Hispanic 3,697 1.3 (0.2) 0.8 (0.2)

Abbreviation: SE = standard error.*Bipolar disorder and schizophrenia are not mutually exclusive.

TABLE 17. Annual average number and rate of ambulatory care visits* for mental health disorders among adults aged ≥18 years, by diagnosis and medical setting — National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), United States, 2007–2008

Primary diagnosis group† ICD-9-CM codes

No. visits (in

thousands)

(SE) (in

thousands)Rate of visits§ (SE)

Medical setting

Physician office (NAMCS)

OPD (NHAMCS)

ED (NHAMCS)

% (SE) % (SE) % (SE)

All diagnoses 961,646 (28,861) 42,982 (1,290) 82.3 (0.9) 8.0 (0.7) 9.7 (0.4)

Mental health disorders 290–319 47,835 (2,534) 2,138 (113) 80.7 (1.6) 11.8 (1.5) 7.5 (0.5)Schizophrenic disorders 295 2,730 (507) 122 (23) 79.4 (4.5) 13.4 (3.3) 7.2 (1.6)Major depressive disorder 296.2–296.3 7,530 (793) 337 (35) 85.0 (2.7) 13.6 (2.6) 1.4 (0.3)Other psychoses 290–294, 296.0–296.1,

296.4–2998,451 (584) 378 (26) 80.8 (2.0) 11.0 (1. 8) 8.3 (0.8)

Anxiety states 300.0 6,679 (544) 299 (24) 84.7 (1.5) 7.0 (1.1) 8.3 (0.9)Neurotic depression 300.4 3,231 (323) 144 (14) 89.6 (1.7) 8.4 (1.6) 2.0 (0.5)Alcohol dependence syndrome 303 653 (116) 29 (5) —¶ (7.4) 38.7 (7.2) 23.5 (4.8)Drug dependence and

nondependent use of drugs304–305 3,164 (459) 141 (21) 40.3 (6.5) 29.8 (7.4) 29.9 (4.5)

Acute reaction to stress and adjustment reaction

308–309 2,778 (308) 124 (14) 81.8 (3.2) 14.5 (3.1) 3.7 (0.7)

Depressive disorder, not elsewhere classified

311 7,299 (622) 326 (28) 85.8 (1.7) 7.9 (1.3) 6.4 (0.8)

Attention deficit disorder 314.0 1,736 (242) 78 (11) 94.6 (1.4) 5.4 (1.4) — (0.0)Other mental disorders 300.1–300.3, 300.5–300.9,

301–302, 306–307, 310, 312–313, 314.1–319

3,585 (494) 160 (22) 83.1 (2.7) 8.5 (1.7) 8.4 (1.5)

Abbreviations: ED = emergency department; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; OPD = outpatient department; SE = standard error.* Visits to physician offices and hospital outpatient and emergency departments.† Primary diagnosis groups are based on a reclassification of codes. § Rate per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized adult population as of July 1, 2007, and July 1, 2008. Additional

information on calculation of rates available at http://www.cdc.gov/nchs/ahcd.htm. ¶ Number does not meet standards of reliability or precision.


Supplement


TABLE 18. Annual average number and rate of ambulatory care visits* for mental health disorders† among adults aged ≥18 years, by age group, sex, and medical setting — National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), United States, 2007–2008

Characteristic

No. (in thousands) and % of visits Rate§ of visits

All three settingsPhysician office

(NAMCS) OPD (NHAMCS) ED (NHAMCS)All three settings

Physician office (NAMCS)

OPD (NHAMCS)

ED (NHAMCS)

No. (SE) % No. (SE) % No. (SE) % No. (SE) % Rate (SE) Rate (SE) Rate (SE) Rate (SE)

Total 47,835 (—) 100 38,621 (—) 80.7 5,630 (—) 11.8 3,584 (—) 7.5 2,138 (—) 1,726 (—) 252 (—) 160 (—)

Age group (yrs) 18–44 22,443 (1,203) 100 17,303 (1,104) 77.1 3,070 (443) 13.7 2,070 (118) 9.2 2,036 (109) 1,570 (100) 279 (40) 188 (11) 45–64 19,451 (1,291) 100 16,205 (1,268) 83.3 2,086 (260) 10.7 1,160 (74) 6.0 2,533 (168) 2,110 (165) 272 (34) 151 (10) ≥65 5,941 (493) 100 5,113 (489) 86.1 474 (76) 8.0 354 (40) 6.0 1,617 (134) 1,392 (133) 129 (21) 96 (11)

Sex Male 18,463 (1,206) 100 14,422 (1,170) 78.1 2,194 (308) 11.9 1,847 (105) 10.0 1,710 (112) 1,336 (108) 203 (29) 171 (10)Female 29,372 (1,584) 100 24,199 (1,511) 82.4 3,436 (425) 11.7 1,737 (105) 5.9 2,537 (137) 2,090 (131) 297 (37) 150 (9)

Abbreviations: ED = emergency department; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; OPD = outpatient department; SE = standard error.* Visits to physician offices and hospital outpatient and emergency departments.† Visits with a primary diagnosis of a mental health disorder (ICD-9-CM codes 290–319).§ Rate per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized population as of July 1, 2007, and July 1, 2008.

TABLE 19. Hospital* discharge rates† among adults aged ≥18 years with mental illness as primary discharge diagnosis, by age group, diagnosis, and sex — National Hospital Discharge Survey, United States, 2007

Primary discharge diagnosis

Age group (yrs)

18–44 45–64 ≥65

Men Women Total Men Women Total Men Women Total

Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE)

Adult mental illness§ 105.7 (14.4) 90.1 (14.7) 97.9 (14.2) 104.9 (12.0) 88.9 (11.4) 96.7 (11.1) 63.7 (9.2) 64.9 (7.0) 64.4 (7.2) Alcohol and drug use

disorders¶32.4 (5.0) 17.5 (3.1) 25.0 (4.0) 44.6 (5.5) 15.4 (2.1) 29.7 (3.6) 12.9 (1.8) 7.6 (1.4) 9.8 (1.2)

Schizophrenia** 18.2 (2.4) 10.4 (1.7) 14.3 (1.9) 17.0 (2.4) 17.1 (3.1) 17.1 (2.3) 5.4 (1.4) 6.6 (1.2) 6.1 (1.0) Mood disorders†† 41.5 (6.8) 50.6 (9.7) 46.0 (8.0) 32.8 (4.7) 44.4 (7.2) 38.7 (5.8) 14.7 (2.4) 22.5 (3.4) 19.2 (2.6) Anxiety, stress, and

adjustment disorders§§3.8 (0.7) 4.5 (0.6) 4.1 (0.5) 2.6 (0.5) 4.7 (0.9) 3.7 (0.5) 1.2 (0.3) 5.3 (1.0) 3.6 (0.6)

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error. * Nonfederal, short-stay (<30 days) hospitals. † Per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized adult population as of July 1, 2007. § ICD-9-CM codes 290–312. ¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1). ** ICD-9-CM code 295. †† ICD-9-CM codes 296, 300.4, and 311. §§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309.

TABLE 20. Hospital* discharge rates† among adults aged ≥18 years with mental illness among any discharge diagnoses, by age group, diag-nosis, and sex — National Hospital Discharge Survey, United States, 2007

Discharge diagnosis (among any listed diagnoses)

Age group (yrs)

18–44 45–64 ≥65


Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE)

Adult mental illness§

220.3 (16.7) 242.7 (18.3) 231.4 (17.0) 394.1 (22.5) 349.2 (20.2) 371.1 (20.4) 580.1 (42.3) 702.3 (38.0) 650.8 (37.6)

Alcohol and drug use disorders¶

107.2 (9.8) 74.7 (7.7) 91.1 (8.6) 166.9 (11.7) 70.9 (5.7) 117.7 (8.2) 90.4 (5.4) 40.7 (3.4) 61.6 (3.5)

Schizophrenia** 24.3 (2.6) 16.1 (1.9) 20.2 (2.1) 32.9 (3.2) 30.1 (3.4) 31.5 (2.8) 19.7 (2.7) 22.2 (2.4) 21.1 (2.1)Mood disorders†† 78.3 (9.8) 125.5 (13.1) 101.7 (11.1) 110.1 (9.8) 163.1 (11.4) 137.3 (10.0) 114.0 (9.5) 219.2 (14.6) 174.9 (11.4)Anxiety, stress,

and adjustment disorders§§

23.2 (2.7) 42.1 (4.1) 32.5 (3.1) 32.6 (2.5) 52.9 (4.1) 43.0 (3.1) 48.5 (3.8) 84.5 (5.5) 69.3 (4.1)

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error. * Nonfederal, short-stay (<30 days) hospitals. † Per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized adult population as of July 1, 2007. § ICD-9-CM codes 290–312. ¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1). ** ICD-9-CM code 295. †† ICD-9-CM codes 296, 300.4, and 311. §§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309.

Supplement


TABLE 21. Percentage of nursing home residents aged ≥65 years with primary diagnosis of mental illness, by age group, diagnosis, and sex — National Nursing Home Survey, United States, 2004

Primary diagnosis

Age group (yrs)

65–74 75–84 ≥85


% (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE)

Alzheimer disease* 4.3 (1.0) 8.2 (1.1) 6.5 (0.8) 11.8 (1.2) 13.7 (0.8) 13.2 (0.7) 9.5 (1.1) 12.6 (0.6) 12.0 (0.6)All adult mental

illness†16.9 (1.8) 20.0 (1.7) 18.7 (1.3) 18.8 (1.4) 20.4 (0.9) 20.0 (0.8) 21.3 (1.5) 23.9 (0.8) 23.5 (0.7)

Dementia§ 7.5 (1.2) 7.0 (1.0) 7.2 (0.8) 13.2 (1.1) 13.9 (0.8) 13.7 (0.7) 15.6 (1.3) 19.2 (0.8) 18.6 (0.7)Alcohol and drug

use disorders¶0.8 (0.4) 0.3 (0.2) 0.5 (0.2) 0.6 (0.3) 0.1 (0.1) 0.2 (0.1) —¶¶ —¶¶ — — — —

Schizophrenia** 3.4 (0.8) 5.9 (1.0) 4.8 (0.7) 1.5 (0.4) 2.2 (0.3) 2.0 (0.3) — — 0.5 (0.1) 0.5 (0.1)Mood disorders†† 1.6 (0.6) 3.2 (0.7) 2.5 (0.4) 1.4 (0.4) 2.2 (0.3) 1.9 (0.2) 2.1 (0.5) 1.8 (0.2) 1.9 (0.2)Anxiety, stress,


0.3 (0.2) 1.3 (0.4) 0.9 (0.3) 0.1 (0.1) 0.5 (0.1) 0.4 (0.1) 0.5 (0.3) 0.3 (0.1) 0.3 (0.1)

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error. * ICD-9-CM code 331.0. † ICD-9-CM codes 290–312. § ICD-9-CM codes 290 and 294. ¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1). ** ICD-9-CM code 295. †† ICD-9-CM codes 296, 300.4, and 311. §§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309. ¶¶ Estimate is unreliable. Relative standard error >30%.

TABLE 22. Percentage of nursing home residents aged ≥65 years with any diagnosis of mental illness among all diagnoses, by age group, diagnosis, and sex — National Nursing Home Survey, United States, 2004

Mental health diagnosis (among all diagnoses)

Age group (yrs)

65–74 75–84 ≥85


% (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE)

Alzheimer disease* 6.8 (1.1) 12.3 (1.3) 10.0 (0.9) 17.0 (1.3) 19.2 (0.9) 18.5 (0.8) 15.7 (1.3) 18.9 (0.7) 18.4 (0.7) All adult mental

illness†60.4 (2.4) 62.5 (2.0) 61.6 (1.6) 62.7 (1.6) 67.4 (1.1) 66.0 (1.0) 63.2 (1.8) 68.7 (0.9) 67.7 (0.8)

Dementia§ 25.1 (2.0) 24.5 (1.7) 24.8 (1.3) 35.9 (1.6) 34.5 (1.1) 34.9 (0.9) 38.3 (1.7) 41.6 (0.9) 41.0 (0.9)Alcohol and drug

use disorders¶5.6 (1.1) 1.9 (0.5) 3.5 (0.6) 2.2 (0.5) 0.7 (0.2) 1.2 (0.2) —¶¶ — — — 0.5 (0.1)

Schizophrenia** 7.3 (1.2) 12.0 (1.4) 10.0 (1.0) 4.2 (0.7) 4.6 (0.5) 4.5 (0.4) — — 1.2 (0.2) 1.1 (0.2)Mood disorders†† 33.3 (2.3) 34.6 (1.9) 34.0 (1.5) 30.0 (1.5) 39.4 (1.1) 36.6 (1.0) 31.0 (1.6) 36.2 (0.9) 35.3 (0.8)Anxiety, stress,


10.0 (1.3) 12.9 (1.3) 11.7 (0.9) 7.2 (0.8) 14.4 (0.8) 12.2 (0.6) 8.1 (1.0) 12.5 (0.6) 11.7 (0.5)

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error. * ICD-9-CM code 331.0. † ICD-9-CM codes 290–312. § ICD-9-CM codes 290 and 294. ¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1). ** ICD-9-CM code 295. †† ICD-9-CM codes 296, 300.4, and 311. §§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309. ¶¶ Estimate is unreliable. Relative standard error >30%.

Supplement

U.S. Government Printing Office: 2011-723-011/21079 Region IV ISSN: 1546-0738

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